Capsule magazine October

Capsule Magazine

EDITORDr. S. Senthil Kumar

PATRONSDr. S. ChandrakumarDr. S. Manivannan

ADVISORY BOARD

Capsule Magazine is publishedby Kauvery Hospital

Copyright 2015 Kauvery Hospital

EDITORIAL TEAMDr. S. VelmuruganDr. S. Aravinda KumarDr. Iyyappan Ponnuswamy

TECHNICAL TEAMDr. Ve. Senthil Vel MuruganDr. A. Subramanian

DESIGN & LAYOUTMr. Vahid Ali N.

EDITORIAL OFFICEKauvery HospitalVI Floor, Administrative Office,#6, Royal Road, Cantonment,Tiruchirappalli-620001.Call us at (431) 40 77 777Mail us at: [email protected] us at: www.kauveryhospital.com

Capsule Magazine | October 2015

Dr. D SenguttuvanDr. Aravindan SelvarajDr. T. Senthil Kumar

ADMIN TEAMMr. A. MadhavanMr. P. CharlesMrs. JPJ. Bindhu

CO-ORDINATORSMrs. PercyMr. Prakash Ranjith Kumar R.

Capsule Magazine | Content

03

PEDIATRIC FOREIGN BODY ASPIRATION

02

PATENT DUCTUS ARTERIOSUS

01 FROM THE EDITORS DESK

07

05

MINIMALLY INVASIVE TRANS THORACIC TREATMENT OFGIANT THORACIC DISC HERNIATIONS

08 RARE CAUSE FOR ACUTE BREATHLESSNESS

ODONTOID SCREW FIXATION IN -TYPE II ODONTOID FRACTUREIN A NEUROLOGICALLY INTACT PERSON

09

11

ACUTE SCROTUM

12 A TRIPLE VALVE SURGERY

13

HEMIPLEGIA

KAUVERY HEARTCITY TRICHY MARATHON15

INTRACRANIAL FOREIGN BODY MASQUERADING AS HYPODENSE INJURY TRACT-A CASE REPORT

| Capsule Magazine | October 2015

Dear Friends,Greetings! At the outset I take this opportunity on behalf of all the consultants of kauvery hospital to congratulate the Team Marathon for their excellent show on 27/09/2015 (World heart day). Kauvery hospital regularly has conducted many such events in the past. Now it is for the health of every ones heart. More than 10000 people across ages participated in this event. Once again a hearty appreciation to the team.

In this edition, I would like to share a concept excerpted from a self help book.

WANT TO MAKE MONEY?It is perfectly natural, in fact it is highly desirable to make money and accumulate wealth. Money gives power to our family and standard of living we deserve. The person who says he wants to be poor usually suffers from a guilty complex or a feeling of inadequacy.

FROMTHE EDITORSDESK

Dr. S. Senthil Kumar, M.S., DNB., (Uro)Senior Consultant Urologist

Want to make money? Then get the PUT SERVICE FIRST ATTITUDE. What is puzzling about money is that people use the backward approach to make it. Everywhere you see people with money first attitude. Yet these people always have little money. Why? Because money cant be harvested unless they plant the seeds that grow money. The seed of money is service. Thats why PUT SERVICE FIRST is an attitude which creates wealth. Put service first and money flows in by itself.

Here is a simple but powerful rule that will help you to develop the put service first attitude. always give people more than they expect to get. Each little extra service you render others is a money seed. Giving customers extra service is a money seed because it brings customer back. Plant service and harvest money.

At Kauvery Hospital,we constantly strive to givethat EXTRA SERVICE toour patients at all levels.

Editors Desk | Capsule Magazine


Intracranial Foreign Body Masquerading | Capsule Magazine

Dr. K. Madhusuthan, MS., M.Ch., MRCSConsultant Neurosurgeon

Kauvery Hospital, Tennur, Trichy

INTRACRANIAL FOREIGN BODYMASQUERADING AS HYPODENSEINJURY TRACT- A CASE REPORT

46 Year old male had a fall under the influence of alcohol and injured his right eye. He had a stick protruding from his right eyebrow and about 2cm of the stick had been removed. The patient was then referred to an opthal institute from where he was referred to our hospital as the patient was drowsy and disoriented.

Patient's GCS was 10/15 . His right globe was completely ruptured. He was evaluated with CT scan brain which showed fracture of greater wing of sphenoid and a hypodensity in the anterior temporal lobe.

Since there was a history of FB that was removed it was suggested as probable tract of FB which entered brain. Foreign body usually present as hyperdensity in CT rather than hypodensity. So MRI was done which showed the foreign body entering the right temporal lobe from the roof of orbit. The size of the FB was roughly around 4 cm. The FB was nearby to intracranial carotid artery.

Hence a right pterional craniotomy was done and carotid artery was delineated and packed between the artery and FB to prevent any undue injury to the artery during removal. Right eye was enucleated and the FB was removed. It was about 7cm long and 2cm thick.

Post op scan showed no bleed in temporal lobe.Patient improved well without further deficit.

PRE OP CT BRAIN POST OP CT BRAIN

PATENTDUCTUSARTERIOSUS

SYMPTOMS

Prevalence is higherin immature newborns,

about 20%, out of which 12%are hemodynamically unstable.

The incidence is1 to 2500 -5000 ofnewborns to term.

Patent Ductus Arteriosus | Capsule Magazine

Persistence from fetal life ofthe communication betweenthe pulmonary artery anddescendant aorta is calledPATENT DUCTUS ARTERIOSUS

Symptoms of patent dustus arteriosus are variable, from asymptomatic state to cardiovascular shock and death. The magnitude of symptoms depends on the size of ductus arteriosus and peripheral pulmonary vascular resistances. The clinical examination may reveal a trill on auscultation, a systolic-diastolic murmur, wide apexian shock, tachycardia, hypotension. Large patent ductus arteriosus gives a murmur that sounds slowly or is absent. The left atrium and left ventricle are dilated due to increased volume of blood which is returning from the lungs. The result of this left-right shunt, is the appearance of pulmonary and systemic signs: manifestations of heart failure, tachycardia, gallop rhythm, pulmonary edema and hepatomegaly. By decreasing of the aortic blood flow, distal from ductus arteriosus, abdominal organs perfusion will be inadequate and will appear oliguria, ileus and acidosis.

PATENT DUCTUSARTERIOSUS

CONNECTINGAORTA TO

PULMONARYARTERY

20%

12%

Page 03 | Capsule Magazine | October 2015

DIAGNOSIS OF PATENT DUCTUS ARTERIOSUS:

TREATMENT OFPATENT DUCTUSARTERIOSUS:

ECG shows signs of the left ventricle and left atrium overloading, right ventricular hypertrophy occurs later with the increasing of pulmonary vascular resistance.

ECHOCARDIOGRAPHYDoppler color method is showing the shunt between the large vessels and its direction. With this exploration can be examined the heart cavities left ventricle, left atrium and cardiac valvular function.

CHEST RADIOGRAPHYIn large patent ductus

arteriosus, radiography is showing signs of pulmonary

overloading, signs of pulmonary edema and

cardiomegaly due to left atrial and left ventricle dilatation.

Krubakaran is a delightful little one year old male child who is the younger of two children born to consanguineous parents. He was detected to have cardiac problem soon after birth in the form of Patent Ductus Arteriosus (PDA). This is a tubular communication between the two outflow tubes from the heart, the Aorta and the Pulmonary artery. The PDA is an essential communication when the baby is present in the mother`s womb and channels the nutritious maternal blood to the baby`s body for purpose of growth and sustenance. After birth, the PDA constricts and gradually closes off completely leaving only a ligamentous structure with no lumen. However, in certain babies, the PDA does not close completely. This results in a communication which allows excess blood flow to the lungs which then causes congestion in the lungs leading to breathing difficulty, feeding

difficulties and poor weight gain. The increased blood flow to the lungs may also contribute to an unhealthy increase in blood pressure in the lungs and damage to the lungs if the problem is not addressed early in life. Hence it becomes necessary to close the PDA in early life when the children are symptomatic.

Krubakaran was weighing a paltry 6 kg even though he was one year of age. This gross underweight was a result of the cardiac problem. Additionally his height was stunted due to congenital growth hormone deficiency, a condition which is made famous by the fact that Lionel Messi was born with it! Growth hormone injections being hugely expensive, the parents were unable to seek help for the cardiac problem even though they were made aware of the condition in the early months of his life. It was recently that a colleague of mine referred the child to Kauvery Hospital after coming to know that interventional procedures were being done free of cost with the help of

SAMAHOPE and the State Health Insurance Scheme.

Krubakaran was admitted on 26th July 2015. He was taken to the cath lab on 27th July 2015 and underwent successful device closure of his PDA. He was monitored in the ICU and after 24 hours was discharged after a detailed evaluation which revealed normalisation of his cardiac status. The mother of the child was overjoyed and could hardly hide her amazement at the rapidity with which her son recovered post procedure.

Patent Ductus Arteriosus | Capsule Magazine

CARDIAC CATHETERIZATIONIn large patent ductus arteriosus,

radiography is showing signs of pulmonary overloading, signs of

pulmonary edema and cardiomegaly due to left atrial

and left ventricle dilatation.


Dr. R. Prem Sekar, MD., DM., FNB., FSCAISenior Consultant

Interventional Paediatric CardiologistKauvery Hospital, Chennai

Pediatric Foreign Body Aspiration | Capsule Magazine


PEDIATRICFOREIGN BODYASPIRATION

Foreign body (FB) aspiration remains a significant cause of morbidity and mortality especially in young children. Suspicion of FB aspiration in children is raised with sudden paroxysms of coughing when not directly supervised, sudden choking after eating particularly when an older sibling feeds a younger sibling, or choking and coughing when a known, small object or food particles are within reach of the child.Foreign body aspiration can result in a spectrum of presentations, from minimal symptoms, often unobserved, to respiratory compromise, failure, and even death.

Foreign body aspiration is a relatively commonly encountered emergency in the pediatric age group. Foreign body can get lodged at any site from supraglottis to the terminal bronchioles. Diagnostic delay may cause an increase in mortality and morbidity in cases without acute respiratory failure.

> age 1

Children aged 1-3 years are particularly at risk because of their increasing independence, lessening of close parental supervision as they become older, increasing activity and curiosity.In infants aged less than 1 year, the foreign body aspiration is the leading cause of accidental deaths.

age 1

age 2

age 3

The aspiration of FB by no means is an uncommon occurrenceespecially in the pediatric age group 5. Majority of FB aspirationoccurs in children 1 to 3 years of age 6. In infants aged less than 1 year, the foreign body aspiration is the leading cause of accidental deaths.

The inhaled foreign body can get impacted at any site from the laryngeal inlet to the terminal bronchioles. The location of foreign

body in the right or left main bronchus depends on patients age and physical position at the time of inhalation. The angle made by the main stem bronchi with the trachea is similar until the age of 15 years. So naturally, up to this age the foreign bodies are found on either side with equal frequency. As a result of growth and development after the age of 15 years, the right and left main stem bronchi diverge from the trachea with very different angles. Thus the right main stem bronchus becomes more in line with the trachea and this makes a relatively straight path from the larynx to bronchus. Therefore, in adults the inhaled objects that descend beyond the trachea are more commonly found in the right than the left side of the bronchial tree.

The majority of aspirated objects are organic in nature, mainly food. Peanuts are the cause most commonly identified by different authors, but some mention melon and sunflower seeds as the predominant causes. This variation in types of organic materials can be explained by cultural, regional and feeding habit differences.

The high incidence of aspirated seeds is related to the absence of molar tooth development between 2 and 3 years of age. This results in an inadequate chewing process, therefore the offering of chunks of food and seeds of any kind to this age group should be avoided. It is also strongly recommended that younger children should not be allowed to play with small plastic or metallic objects.

Management of inhaled foreign body depends on the site of impaction of foreign body. Laryngeal and subglottic foreign bodies need urgent intervention in the form of tracheostomy or urgent bronchoscopy, whereas foreign bodies in the right or left main

CASE REPORT: DISCUSSION:3yrs old female child had presented with complaints of one week history of cough and cold associated with breathing difficulty. On examination of respiratory system breath sounds were decreased on left side .Routine blood investigations were non contributory. X ray chest (fig1) was taken showed hyperinflation on left side. Computed tomography of chest (fig2) was performed showed hyperinflation of lung on left side with endobronchial obstruction of left

bronchus cause comparatively lesser airway problem. Bronchoscopy should be used as a diagnostic method in cases where the possibility of FB aspiration cannot be ruled out through history, physical and radiological examination. Upon diagnosis, early bronchoscopy is necessary because the earlier the bronchoscopy the lesser the complications.

Both techniques of flexible bronchoscope for diagnostic purposes and the rigid bronchoscope for FB removal provide optimal care for children with FB. Better instrumentation and anesthesia have reduced the complication rate associated with FB removal.

main bronchus. Patient was referred here with suspicion of foreign body.The child was evaluated with rigid bronchoscopy which showed the foreign body (orange seed) , which was removed with optical forceps. She was treated with antibiotics, bronchodilators and other supportive medications. X ray chest (fig3) was repeated on next day which showed radiological improvement. She improved clinically and was discharged after 2 days.

Pediatric Foreign Body Aspiration | Capsule Magazine


CONCLUSION:

Figure 1

Figure 2

Figure 3

The aspiration of FB by no means is an uncommon occurrenceespecially in the pediatric age group 5. Majority of FB aspirationoccurs in children 1 to 3 years of age 6. In infants aged less than 1 year, the foreign body aspiration is the leading cause of accidental deaths.

The inhaled foreign body can get impacted at any site from the laryngeal inlet to the terminal bronchioles. The location of foreign

body in the right or left main bronchus depends on patients age and physical position at the time of inhalation. The angle made by the main stem bronchi with the trachea is similar until the age of 15 years. So naturally, up to this age the foreign bodies are found on either side with equal frequency. As a result of growth and development after the age of 15 years, the right and left main stem bronchi diverge from the trachea with very different angles. Thus the right main stem bronchus becomes more in line with the trachea and this makes a relatively straight path from the larynx to bronchus. Therefore, in adults the inhaled objects that descend beyond the trachea are more commonly found in the right than the left side of the bronchial tree.

The majority of aspirated objects are organic in nature, mainly food. Peanuts are the cause most commonly identified by different authors, but some mention melon and sunflower seeds as the predominant causes. This variation in types of organic materials can be explained by cultural, regional and feeding habit differences.

The high incidence of aspirated seeds is related to the absence of molar tooth development between 2 and 3 years of age. This results in an inadequate chewing process, therefore the offering of chunks of food and seeds of any kind to this age group should be avoided. It is also strongly recommended that younger children should not be allowed to play with small plastic or metallic objects.

Management of inhaled foreign body depends on the site of impaction of foreign body. Laryngeal and subglottic foreign bodies need urgent intervention in the form of tracheostomy or urgent bronchoscopy, whereas foreign bodies in the right or left main

Diagnosis of foreign body aspiration in children is difficult, because it,s presentation can be mistaken as asthma or respiratory tract infection, which leads to delayed diagnosis and treatment, and can result in intrabronchial granuloma formation. Therefore, early bronchoscopy is very effective procedure for inhaled foreign body removal with fewer complications.

bronchus cause comparatively lesser airway problem. Bronchoscopy should be used as a diagnostic method in cases where the possibility of FB aspiration cannot be ruled out through history, physical and radiological examination. Upon diagnosis, early bronchoscopy is necessary because the earlier the bronchoscopy the lesser the complications.

Both techniques of flexible bronchoscope for diagnostic purposes and the rigid bronchoscope for FB removal provide optimal care for children with FB. Better instrumentation and anesthesia have reduced the complication rate associated with FB removal.

Dr. A. Nagarajan, MBBS., DTCD., DNBConsultant Pulmonologist

Kauvery Hospital, Cantonment, Trichy

Thoracic disc herniationis a relatively uncommon

spinal condition withan incidence of

1 case per millionpopulation per year.

Signs and symptoms canvary from obscure

thoracic or abdominalpain to severe myelopathy.

Symptomatic thoracic discherniation is a rareoccasion and onlycomprises0.151.80% ofall surgeries performed forall disc herniations.

Male and female individualsare equally affected.

Progression of the spinal cord compression can result in bowel and bladder dysfunction, gait disturbance, variable sensory and/or motor dysfunction in the lower extremities, and paraplegia. Surgical treatment is indicated in patients with signs of myelopathy or severe radiculopathy that is nonresponsive to conservative treatment. A subgroup of these patients have giant thoracic disc herniations which is described to be more than 70% or more of the diameter of the spinal canal on radiological imaging and majority are

MINIMALLY INVASIVETRANS THORACIC TREATMENT OFGIANT THORACIC DISCHERNIATIONS

ThoracicDisc

Herniations

calcified. There is scant literature on the clinical characteristics, treatment options, and outcome of patients with giant thoracic disc herniations. These remain a surgical challenge and historically have been associated with significant complications. Surgery has significant morbidity of serious neurological damage and paraplegia.

A 65 years old lady presented with a 3-year history of progressive difficulty in walking and mid thoracic pain. Initially she was treated with physiotherapy and conservative management. She started to develop bladder symptoms and became immobile and bed bound for a period of 6 months prior to presentation. She has severe excruciating pain in the thoracic region with paresthesia and tingling in the whole body below T4. Serial MRI scans showed a very large more than 80% calcified thoracic disc herniation at T3/4 level compressing the cord. She had visited several hospitals and she was given a grave outcome with risk of permanent paraplegia.

Giant Thoracic Disc | Capsule Magazine


Dr. S. Aravinda kumar,MD, DNB (cardio).,AFESC .,

Consultant Chief CardiologistKauvery Heartcity, Trichy

Dr. G. Dominic Rodriguez,MBBS., MD., DNB.,

Consultant General MedicineKauvery Hospital, Tennur, Trichy

RARE CAUSEFOR ACUTEBREATHLESSNESS

58 year old female with euglycemic, hypertensive for 3 months was admitted with complaints of progressive worsening of breathlessness for 1 week duration.

Pre operative MRI and CT with Calcified disc

Post operative MRI

CONCLUSION:

Dr. G. Balamurali, MBBS, MRCS, MD, FRCS (Neurosurgery).Consultant Senior Spine & Neurosurgeon.

Kauvery Hospital, Chennai

Under general anaesthesia and left lateral position a right side approach was taken to avoid any necessity of retracting the aorta. Single lung ventilation using a double lumen tube was used. With the help of the Cardio-Thoracic surgeon an approach through the ribs below the axilla was taken. The Arch of aorta was identified and retracted and intervertebral branches tied off. After reconfirming with X rays the head of the rib was removed and the borders of the adjacent pedicles identified. Under the surgical microscope a 5 to 6 mm wide groove was cut into the posterior third of the vertebral body using a high-speed burr drill and a cavity created. Using curettes and dissectors, the soft

Giant Thoracic Disc | Rare Cause for Acute Breathlessness | Capsule Magazine


Anterior decompression using a mini-transthoracic approach provides sufficient exposure for microsurgical decompression of giant thoracic disc herniations without disrupting the stability of the spine. Microsurgical decompression without instrumentation does not appear to lead to vertebral collapse or spinal malalignment. Giant Thoracic disc herniations must be treated by experienced spine surgeons to avoid serious morbidity and paraplegia.

At admission she was tachypneic with resting saturation of 85% and with normal blood pressure and pulse. Her ECG showed features of RV strain and S1, Q3, T3 suggestive of acute pulmonary embolism and her echo cardiogram confirmed severe PAH with RA IRV dilatation.

Provisionally patient was diagnosed to have acute pulmonary embolism and to confirm the diagnosis CT pulmonary angio was done. To our surprise pulmonary vascular tree was normal.

Now we had the diagnostic dilema and differential diagnosis of obesity hypoventilation syndrome, obstructive sleep apnea. ILD, myasthemic gravis was considered. As her condition worsened with CO2 narcosis, she required Intubation and ventilation to wash out CO2.

Her nerve conduction / EMG study revealed feature of myasthemic gravis and her acute onset of breathlessness with CO2 narcosis was finally diagnosed to be due to myasthemic gravis and she promptly improved after treating for the same.

disc herniations were easily separated from the dura, whereas calcified hernias were found to be firmly attached. This was drilled with a diamond burr and gentle dissection on the dura to remove the rest of the calcified disc without any complications. Standard closure with a chest drain was done. Patient was slowly mobilized and was able to stand before discharge. At 4 weeks she was walking with support without any pain and total recovery of her paresthesia. In my previous experience of 7 patients similar excellent results were achieved with only one person developing a CSF leak related problem that improved over time. This has also been published in the European Spine Journal in 2011.


HEMIPLEGIA

An 89 year old gentleman presented with sudden onset of left hemiplegia. His wife found him with left side weakness early in the morning, time of onset was not clear. No history of loss of consciousness or deviation of angle of mouth. His background includes, history of hypertension and previous CVA in 2005. He had right side weakness, secondary to a left side MCA territory infarct and thrombosed left internal carotid artery in 2005. Following this, he was treated with Acitrom and made a good motor recovery on the right with residual very mild aphasia.

On arrival, his GCS was 15/15. BP was 140/90 mm Hg but had profound left side weakness with power 0/5 in the upper limb and 1/5 in the left lowerlimb. He also complained of neck pain. His initial NIHSS score was 6.

Initial CT Brain (Fig 1) showed chronic left MCA territory infarct involving left gangliocapsular region with gliosis. There was no acute infarct or hemorrhage on the right side to account for his left side weakness. Subsequently, MRI brain with MRA brain and neck vessels was done which revealed luminal narrowing of left MCA artery M2 segment and thrombosed left ICA but no acute infarct on the right hemisphere. There was no evidence for any dissection of the neck vessels.

His blood routine were normal but his INR was 3.54 and thus Acitrom was stopped. He also developed abdominal distension on the 3rd day and investigations revealed impacted stools and was treated for constipation by the gastroenterologist.

Since the MRI brain did not explain the left side weakness and considering the history of neck pain, MRI cervical spine with whole spine screening was performed. MRI Cervical spine (FIG 2 & 3)revealed degenerative disc disease from C2 to C7 level. In addition to that, there was a left side posterior epidural hematoma compressing the cervical

Damage to the motor areas onone side of the brain can lead to paralysis

of the opposite side of the body.This one-sided type of paralysis is

known as hemiplegia.

Site of damage

Figure 1

Hemiplegia | Capsule Magazine

Hemiplegia | Capsule Magazine


Dr. Bhuvaneshwari, MBBS., MRCP(UK)., CCT(UK)Consultant Neurologist


Dr. Jeyabarathi, DMRD., FRCR(UK)Consultant Radiologist


Neurosurgical opinion was obtained and it was recommended that patient needs immediate decompression surgery with spine stabilization (in view of the old degenerative changes) but after a lot of deliberation, the family decided that they do not want surgery and wanted only conservative treatment. Patient was treated with steroids to reduce the cord odema and advised bed rest and neck collar for 6-8 weeks for spontaneous resolution of the haematoma to occur. Patient has been stable, there is no progress of weakness and thus discharged. He will be followed up as outpatient with follow up scans to assess progression.

Fig2. MRI axial T2 sequence showswell defined T2 hypointense epiduralhaematoma compressingcervical spinal cord

Fig 3. MR Myelogram showingexternal compressionon the cervical cord

cord from C2 to C5 level and pushing it to the right side. Cervical cord

showed intramedullary cord edema predominantly

confined to left hemicord from C2 to C7 level.

Nerve conduction studies were also performed and this showed evidence for a background sensorimotor axonal neuropathy but there was no evidence for any significant

asymmetry.

On further examination, it was

clear that patient had left side weakness with

severely impaired vibration and position

sensation on the left and there was reduced perception of

pin-prick sensation on the right. Thus this patients presentation was like Brown sequard syndrome explained by the spontaneous cervical posterior epidural haematoma causing hemi-cord transection /dysfunction.

Type II Odontoid Fracture | Capsule Magazine


CT-Demonstrating Type 2 Fracture With Dysplacement MRI Showing Fracture Line And Intact Ligament

10-20%present withneurological deficit .

60-70% Dens fracture patientsare neurologically intact atthe time of presentation.

So these patients arereal anesthetic and surgical

challenge for maintainingnormal neurological status.

30%of dens fractures

are fatal at the time ofaccident.

CASE SUMMARY:Thirty four year old gentleman had sustained RTA (fall from two wheeler) and was evaluated elsewhere with CT scan. He was referred to Kauvery Hospital, Tennur with the diagnosis of odontoid fracture. Patient was on Philadephia collar with intact neurological status. MRI was done to rule out any transverse ligament rupture.

Patient had Type II odontoid fracture with intact transverse ligament. Patient underwent fibro-optic intubation in neutral head position and under fluroscopic guidance to avoid any undue displacement of fracture fragment and compression over cervical cord. Fracture fragments got reduced in mild flexion. To begin with, a guide wire was driven under C-arm control (AP and lateral). Then cannulated drilling and tapping was done. This was followed by insertion of 36 mm cannulated odontoid lag screw under C-arm guidance. Rigid fixation of fracture was achieved with single cancellous screw which had a good purchase over the proximal Dens fragment. Patient had no post operative neurological deficit. Patient was mobilised on the second post operative day.

ODONTOID SCREW FIXATION IN-TYPE II ODONTOID FRACTUREIN A NEUROLOGICALLYINTACT PERSON

Odontoid fracturesare 1/5th of cervicalspine injuries.

Odontoid

Type II Odontoid Fracture | A Triple Valve Surgery | Capsule Magazine


Dr. K. Madhusuthan, MS., M.Ch., MRCSConsultant NeurosurgeonKauvery Hospital, Tennur

Dr. P.R. Ramasamy, M.S..,FRCS.,Consultant Orthopaedic Surgeon

Kauvery Hospital, Tennur

Anderson and D' Alonso ClassificationType ITip of Odontoid fracture

Type IIFracture through the junction of dens and body of C2

Type IIIFracture involving the body of C2

Type I and Type III fractures are usually managed conservatively. Type II fractures need surgical fixation (either anteriorly or posteriorly). Immediate anterior fixation (odontoid screw) has 90% union rate. This is a less morbid procedure which provides anatomical fixation with the preservation of rotational component.

Contra-indication for anterior fixation are; a. Chronic fracture (> 6 months), b. Age > 65, c. Anteriorly oblique fracture, d. Ruptured transverse ligament, e. Barrel chest (relative)

DISCUSSION:

Intraop And Postop XrayShowing Adequate ReductionAnd Compression Of Fragment

A TRIPLE VALVE SURGERY

Mrs. Nallammal aged 24 years female patient, married with 2 children, a known case of Rheumatic Heart diseases presented to our hospital in severe cardiac failure. Her ECG showed atrial fibrillation with fast ventricular rate around 170/min. USG abdomen showed grossly cardiomegaly with bilateral pleural effusion.

Echo was suggestive of severe (MS And MR) Moderate(AS), Severe(AR), Severe(TS), Severe(TR) with severe PAH and severe LV dysfunction.Patient was taken for double valve replacement with Tricuspid Ring Annuloplasty.

Intraoperatively she had gross cardiomegaly. RA, RV, LA and LV Dilated. PA pressure was around 100mmHg. Mitralvalve was replaced with 25mm St. jude mechanical mitral valve with preservation of PML.

Aortic valve was Replaced with 17mm St Jude mechanical Aortic valve.Tricuspid Ring Annuloplasty was done with 28mm Edwards Classic Tricuspid Annuloplasty Ring. Patient was Extubated 3 hours after surgery and discharged on 6th day.

Comment:This operation was really rewarding for the Patient who was very sick and in Severe cardiac failure. She dramatically improved in a period of a week and discharged in a stable condition.

Alternate 3 to 4 inchminimally invasiveincision for some

mitral valve surgeries

6 to 8 inch incision madedown the center

of the sternum (breastbone)for traditional valve surgery

3 to 4 inch minimallyinvasive incision

for mitral and tricuspidvalve surgeries

Dr. M. Ashiq Nihmathullah, M.S., Mch.,Consultant Cardio-Vascular & Thoracic Surgeon

Kauvery Heartcity, Trichy

Acute Scrotum | Capsule Magazine


Acute painful condition of scrotum or its contents is a urological emergency which if not treated promptly can result in testicular loss or infertility. It is urologist's equivalent to the general surgeon's "acute abdomen". Here we will have an overview of acute scrotum and discuss briefly the management and outcome of our patient who was presented with acute scrotum.

Thorough clinical history to characterize the pain associated symptoms like vomiting, fever, urinary symptoms should be elicited, gentle clinical examination should be done to look for any erythema of the scrotum, laterality, swelling and tenderness of scrotum and testis. Lie and position of the testis gives valuable information about the underlying condition. Prehn; sign is not reliable to differentiate torsion from other causes. Ipsilateral absence of cremasteric reflex correlates well with torsion testis in 100% of the cases (Rabinowitz 1984). While the differential diagnosis is broad, an accurate history and physical examination can frequently, precisely define the condition. Often, carefully chosen imaging studies can complement clinical judgment and expedite therapeutic decisions.

Torsion of spermatic cord Torsion of appendix testis/epididymis Epididymitis Epididymo-orchitis Trauma /insect bite Inguinal hernia Inflammatory vasculitis [HSP]

ACUTE SCROTUM

EVALUATION:

Scrotal exploration was done within two hours after presentation under regional anaesthesia after getting informed consent. Intraoperatively left spermatic cord was found to have undergone 360 degrees torsion intravaginally [Figure 2]. Left testis regained vascularity after detorsion and warm packing for 30 minutes[Figure 3]. Bilateral eversion of tunica vaginalis was done along with orchidopexy using 3`0 vicryl by three point fixation technique.

MANAGEMENT:

Figure 1:Colour Doppler showing absentflow on the left side

Nineteen year old college student presented with

sudden onset of left side testicular pain

lasting for the past 3 hours. There was no associated vomiting,

fever or urinary symptoms. Clinical

examination revealed a tender, mildly

enlarged left testis with absence of

cremasteric reflex on that side. Urgent scrotal Doppler

showed no flow on the left side with

normal findings on the right testicles

[Figure 1].

CASEPRESENTATION:

Acute Scrotum | Capsule Magazine


Patient had a remarkable postoperative recovery with

repeat Doppler at 3 weeks showing adequate perfusion

on that side.

OUTCOME:

Testis torsion is the most common cause of testicular loss in adolescents and neonates. The incidence in males 12 hours; and virtually no viability if detorsion is delayed >24 hours.

This event has been a benchmark in the history of Trichy because to remember the world heart day there was a huge participation of more than 10,000 participants in the Marathon.

There was about 6000 participants in 5K, 4000 participants in 10K and 300 participants in 21K.

We are proud to share that participants across nations participated in this event.

TRICHY MARATHONKauvery Heartcity

Kauvery Heartcity Trichy Marathon | Capsule Magazine



RADIOLOGY QUIZ | Capsule Magazine

RADIOLOGY

QUESTION1. Name of the investigation?2. Diagnosis?

Answer the Quiz toEmaill: [email protected] orWhatsapp: 98434 12380and win Surprize Gift

Please send the answers with your full name and mobile number.The correct answers and winner will be disclosed in the next capsule edition.

Kauvery Hospital, No.1, K.C. Road,Tennur, Trichy - 17. Ph: 0431-4022555Kauvery Hospital, No.6, Royal Road, Cantonment, Trichy - 1. Ph: 0431-4077777

Kauvery Hospital Heartcity, No.52, Alexandria Road, Cantonment, Trichy - 1. Ph: 0431-4003500Kauvery Hospital Lifestyle Building, No.81, TTK Road,Alwarpet, Chennai - 18. Ph: 044-40006000

Kauvery Medical Centre, No.42/1, Kuruchiyental, Mudiyarasanar Salai, Maruthupandiyar Nagar, Karaikudi Ph: 04565-244555

A NEURO SURGERY

THAT LEAVES AS TINY

AN INCISION AS CAN BE

COVERED BY A BAND-AID?

POSSIBLE.Brain tumour surgeryHead injury surgery

Stroke treatmentNeuro Critical care unit

DEPARTMENT OFNEUROSCIENCES

THE NEW AGE FAMILY HOSPITAL

World class panel of doctors | State of art equipment | Best in class amenities

E: [email protected] W: www.kauveryhospital.com

Documents

Capsule magazine October